Letter to the Editor: Examining the Usage of Medications on the Beers Criteria List in the Community Setting
Examining the Usage of Medications on the Beers Criteria List in the Community Setting
The 2012 release of the American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults continued to shine light on the persistent problem regarding medication use in the elderly population. From 2000 to 2010, the population of adults 65 years of age or older increased from 35 million to 40 million.1 It is estimated that by 2020, that number will increase by 36%, so there will be nearly 55 million adults aged 65 years or older.1 This increase is partly due to advancements in modern medicine and technology. As a result of these developments, the average age expectancy has increased over the years. One result of this increased life expectancy is older adults’ chronic conditions being managed with more prescription medications. It is predicted that the average older adult uses five prescription medications. Elderly patients with three or more chronic conditions use six to seven prescription medications per month. Most medication-related problems are preventable in older adults, but statistics prove that we as healthcare providers are not appropriately managing our elderly population. Based on past studies in ambulatory and long-term care settings, 27% and 42% of adverse drug events, respectively, are preventable.2
Recently, there was a study published in the New England Journal of Medicine (NEJM; www.nejm.org/doi/full/10.1056/NEJMsa1103053) that addresses emergency hospitalizations in older Americans due to preventable adverse drug events. The study revealed that an estimated 265,802 emergency department visits for adverse drug events occurred annually from 2007 through 2009 among adults 65 years of age or older. Approximately 37.5% of these visits required hospitalization. An interesting finding in this study was that the proportion of emergency department visits resulting in hospitalization due to drugs on the Beers Criteria list was 42%.3
At my clinical site, I decided to review the number of patients who are currently on medications that are included on the Beers Criteria list. Using the Outcomes system, which is a nationwide network of pharmacists designed to deliver medication therapy management services, I reviewed the medication profiles of 41 patients aged 65 years and older. Since I do not have direct contact with each patient’s physician, I excluded particular medications from the study. The following medications were excluded: nonsteroidal anti-inflammatory drugs, except for ketorolac and indomethacin, due to unawareness of the frequency of therapy (chronic vs acute) and whether alternatives were initiated first; metoclopramide and alpha1-blockers, because the official diagnosis for which the patient was taking the medication was unknown; and spironolactone, because kidney function and the presence of heart failure could not be determined. According to the results, 16 of 41 patients were on a medication from the Beers Criteria list. When examining the medications used by these 16 patients more closely, a total of 21 medications were on the Beers list. After dividing the medications into categories, the breakdown was as follows: 38.1% were cardiovascular medications; 28.6% were central nervous system medications; 9.5% were gastrointestinal medications; 19.0% were pain medications; and 4.8% were other medications.
When reviewing the cardiovascular agents, the most common agent that patients were on was clonidine (~38%). That was an interesting finding because in the NEJM article that I referred to earlier, approximately 39.6% of the proportion of emergency department visits resulting in hospitalization due to cardiovascular agents was the result of dizziness, syncope, or fall or other injury. Two of the more pronounced adverse effects of clonidine in the elderly are drowsiness and dizziness. Based on this particular finding, I believe we need to be more cautious with our usage of clonidine in the geriatric population. Another intriguing finding is that only three patients were on benzodiazepines. Benzodiazepines are frequently prescribed in older adults and have a pronounced effect on the central nervous system of the elderly. It was surprising that more patients were not on this class of medication.
Although this is a small sample size of the general population, I do believe that it is an accurate depiction of the improper prescribing of medications to the elderly. As healthcare professionals, we must improve on our ability to properly manage drug therapy among the geriatric population. As time goes on, the number of older adults will continue to increase. We must be prepared to properly and effectively treat this growing patient population.
Jonathan Newsome, PharmD
Department of Pharmacy Practice
Dr. Newsome reports no relevant financial relationships.
1. US Department of Health and Human Services, Administration on Aging. A profile of older Americans: 2011. www.aoa.gov/aoaroot/aging_statistics/Profile/2011/docs/2011profile.pdf. Accessed August 1, 2012.
2. The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616-631.
3. Budnitz D, Lovegrove M, Shehab N, Richards C. Emergency hospitalizations for adverse drug events in older americans. New Eng J Med. 2011;365(21):2002-2012.